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Click here or scroll down to respond to this candidateCandidate's Name
Street Address PHONE NUMBER AVAILABLE EMAIL AVAILABLECustomer-focused HEALTH PLAN PROFESSIONAL and TELECOMMUNICATION with experience in providing high quality, detail oriented, comprehensive services to providers and members. Able to utilize active listening skills and problems solving techniques.TECHNICAL PROFICIENCIESMS Office Professional: Word, Excel, PowerPoint, Project, Visio, Outlook, NetMeeting, Zoom, Office Communicator, Publisher, Right Fax Systems, Adobe Acrobat Professional, AutoCAD 5.0Healthcare Computer Applications: TRUCARE, PRIME, US Script/Envolve Web Application, AWD Prod, Faxcom, CITRIX Access Platform, FOCUS (Behavioral Health), NIA (Imaging), MCMC (Health Specialists), MMIS (Medicaid/Medicare Patient Access), CRM Prod, CNET (Web Applications), AMISYS Advance V6 (Health Plans and Directory), ADP Web Applications, OMNI, Portico, EDI, MicroStrategy (Member Rx DUR / Biography), APEX Leadership training, DCH CMO Georgia Families Mandatory Medicaid Training, Oracle Database SQL Workshop.AREAS OF EXPERTISECustomer ServiceProvider RelationsDenial/Appeals/GrievanceICD-9, 10 CodesCPT CodesClinical ProcessesMember ComplianceVendor RelationsDocument ReportingPROFESSIONAL WORK EXPERIENCEPeach State Health Plan, Atlanta, GA (Centene Corporation)(June 2008 through December 8th 2023) Details Below.Denial Coordinator/ Utilization Management 05/2018 to 12/2023Generates and processes denial letters and Notice of Action for pre and post services, leveling of care and denied medical services.Maintains the denial logs and assessments in accordance with state, federal, and corporate guidelines.Responsible for the Medical Management denial process including letter printing, tracking and disposition of letters within contractual guidelines to ensure compliance.Maintains confidentiality of patient information.Serve as the department liaison for all denial processTrain others on denial and/or appeals work processesGrievance & Appeals Coordinator/ Quality Improvement 11/2017 to 6/2018Analyze and resolve verbal and written claims and authorization appeals from providers and pursue resolution of formal grievances from members.Gather, analyze and report verbal and written member and provider complaints, grievances and appealsPrepare response letters for member and provider complaints, grievances and appealsMaintain files on individual appeals and grievancesResponsible for HEDIS production functions including data entry, calls to providers offices, and claims research. Manage large volumes of documents including copying, faxing and scanning incoming mailCandidate's Name
Denial and Appeal Coordinator/ Quality improvement 03/2015 to 12/2017Generates and processes denial letters and Notice of Action for pre and post services, leveling of care and denied medical services.Maintains the denial and/or appeals logs and assessments in accordance with state, federal, and corporate guidelines.Responsible for the Medical Management denial process including letter printing, tracking and disposition of letters within contractual guidelines to ensure compliance.Maintains confidentiality of patient information.Program Coordinator Case Management/Disease Management 04/2012 to 03/2015Conduct screenings for eligibility and benefits.Answer phone queues and faxes and compose and mail letters to members and providers.Provides departmental support for member services by attending ongoing trainings and seminars.Referral Specialist 06/2008 to 04/2012Initiated authorization requests for output or input services.Reviewed codes, appeals, denials and clinical processes.Researched claims inquiries specific to the department.Provides high quality, comprehensive services to members and providers.TerraGo Technologies Atlanta, GAMap Technician/Analyst: 03/2004 to 12/2007Verified the accuracy of map coordinate for navigation purpose and reports.Perform geographical distance on all maps globally for Armed forces / government usage.Lucent Technologies Atlanta, GAPower Systems Engineer: 1/1997 to 12/2002Analyzed documents and process power specifications for telecommunication equipment.Win-Track application was used as a tool to provide Field Engineer direct access to EngineeringCreated ideas on how to process Com-codes (for buying purposes (WINTRACK))AutoCad application used to process Power System equipment for installation purposes.Delivered specifications in a timely manner. Awarded for on time delivery of projects.EDUCATION AND CERTIFICATIONSUniversity of Phoenix- Atlanta Campus 1999 Sandy Springs, GAProject Management Professional (PMP)Grambling State University Grambling, LABachelor of Computer Information Systems (BSc CIS)Graduated 1989Completed Georgia Families Mandatory Medicaid Training 4/2019 Atlanta, GAAPEX Leadership training. |
